NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY.
This Notice is effective as of: 09/01/2006
We are required by law to maintain the privacy of protected health information, and must inform you of our privacy practices and legal duties. You have the right to obtain a paper copy of this notice upon request.
We are required to abide by the terms of the Notice of Privacy Practice that is most current. We reserve the right to change the term of the Notice at anytime. Any changes will be effective for protected health information that we maintain. The revised Notice will be posted in the waiting room (IF APPLICABLE: and on our website). You may request a copy of the revised Notice at a time.
We have designated a Privacy Officer to answer your questions about our privacy practices and to ensure that we comply with applicable laws and regulations. The Privacy Officer also will take your complaints and give you information about how to file a complaint.
Our Privacy Officer is: Pat Hodgson you can contact the Privacy Officer at: (847) 518-0442.
Use and disclosure of your protected health information that we may make to carry out treatment, payment and health care operations.
We may use information in your record to provide treatment to you. We may disclose information in your record to help you get health care services from another provider, a hospital, etc. For example, if we went an opinion about your condition from a specialist, we may disclose information to the specialist to obtain consultation.
We may use or disclose information from your record to obtain payment for the services you receive. For example, we may submit your diagnosis with a health insurance claim in order to demonstrate to the insurer that the services should be covered. We may use or disclose information from your record to allow “health care operations.” These operations include activities like reviewing records to see how care can be improved, contacting you with information about treatment alternatives, and coordinating care with other providers. For example, we may use information in your record to train our staff about your condition and its treatment.
Your rights:
You may ask to restrict the use and disclosure of certain information in your record that otherwise would be allowed for treatment, payment or health care operations.
However, we do not have to agree to these restrictions. You have the right to receive confidential communications from us. For example, if you want to receive bills and other information at an alternative address, please notify us.
You have a right to inspect the information in your record, and may obtain a copy of it. This subject to certain limitations and fees. Your request must be in writing.
If you believe information in your record is inaccurate or incomplete, you may request amen of the information. You must submit sufficient information to support your request for amen your request must be in writing. You have the right to request an accounting of certain disclosures made by us.
You have the right to complain to us about our privacy practices (including the actions of our with respect to the privacy of your health information). You have the right to complain to the Secretary of the Department of Health and Human Services about our Privacy practices. You do not face retaliation from us for making complaints.
Except as described in this Notice, we may not make any use or disclose of information from record unless you give your written authorization. You may revoke an authorization in writing anytime, but this will not affect any use or disclosure made by us before the revocation. In addition, if the authorization was obtained as a condition of obtaining insurance coverage, the insurer may have the right to contest the policy or a claim under the policy even if you revoke the authorization.
Use or disclosure of your protected health information that we are required to make with your permission.
In certain circumstances, we are required by law to make a disclosure of your health information for example; state law requires us to report suspect child abuse or neglect. Also, we must disclose information of the department of health and human services, if requested, to prove that we are complying with regulations that safeguard your health
Information:
NOTE TO PACKAGE USERS: INSERT DESCRIPTION OR OTHER REQUIRED DISCLOSURE ACCORDING TO YOUR STATE AND PROFESSIONAL DISICIPLINE (see below).
Use or disclosure of your protected health information that we are allowed to make without your permission.
There are certain situations where we are allowed to disclose information from your record with your permission. In these situations, we must use our professional judgment before disclosing information about you. Usually, we must determine that the disclosure is in your best interest, and may certain guidelines and limitations.
If you receive mental health care, including treatment for substance abuse, information related to that care may be more protected than other forms of health information. Communication between a psychotherapist and patient in treatment are privileged and may not be disclosed without your permission, except as required by law. For example; psychotherapist still must report suspected child abuse, and may have to breach confidentiality if you appear to pose an imminent danger to yourself or others, in order to reduce the likelihood of harm to you or others.
NOTE TO PACKAGE USERS: Some or all of the following clauses should be moved up to the previous section, if they are required by law in your state, for your Profession. Some modification of the wording may be necessary.
We may use or disclose Information from your record if we believe it is necessary to prevent or lessen a serious and imminent threat to the safety of a person or the public. We may report suspected cases of abuse, neglect, or domestic violence involving adult disabled victims. We may report deaths to public health authorities, as well as certain types of diseases, injuries, adverse drug reaction, and product defects. We may disclose information from your records to facilitate organ, eye, or tissue donation and transplantation. We may assist in health oversight activities, such as investigations of possible health care fraud. We may disclose information from your record as authorization by workers’ compensation laws. We may disclose information from your record if ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even if this is not ordered by court.
We may disclose information from your record to law enforcement official if certain criteria are met. For example, if such information would help locate or identify a missing person, we are allowed to disclose it. If you tell us that you have committed a violet crime that caused serious physical harm to the victim, we may disclose that information to law enforcement officials. However, if you reveal that information in a counseling or psychotherapy session, or in the course of the treatment for this sort of behavior, we may not disclose the information to law enforcement officials. We may use or disclose information from your records for research under certain conditions. Under certain conditions, we may disclose information for specialized government purposes, such as the military, national security and intelligence, or protection of the president.
IF APPLICABLE: Your provider (or office staff) may contact you to provide appointment reminder as a courtesy. However, you are responsible for remembering your appointment.
IF APPLICABLE: We may contact you with information about treatment alternatives or other health-related benefits or services that may be of interest to you.
IF APPLICABLE: We may contact you for fundraising efforts.